HealthPartners Overview of End-of-Life Care & Advance Care Planning

Honoring Choices MinnesotaJuly 19, 2012

End of Life/Palliative Care Steering Committee

Co-chairs: Tom von Sternberg, MD, Beth Waterman

Membership includes representatives from Regions Hospital, Specialty Care, HealthPartners Home Care, Geriatrics,

Hospice & Palliative Care, Primary Care and the Health Plan

Areas of Focus:

HOME CARE, GERIATRICS, HOSPICE &

PALLIATIVE CARE

REGIONS HEALTH PLAN

PRIMARY CARE

SPECIALTY CARE COMMUNITY

-Jim Risser, MD-Beth Heinz-Danielle Tencate Cole

-Lora Heidin-Karen Kraemer

-Kate Kellet -Terry Carter-Tyler Schmidtz-Rachel Nygard

-Mary Lou Irvine-Tom von Sternberg, MD-Beth Werner

-Mary Lou Irvine-Tom von Sternberg, MD-Donna Zimmerman-Beth Heinz

Regions

Palliative Care referrals• Criteria in Epic

• Auto referral for Medical ICU patients over 85

• Surgical ICU will add auto referral

• Presence at care rounds

• Expanding to Emergency Dept: Physician Orders for Life Sustaining Treatment (POLST) and consults

• Increasing Palliative Care provider coverage

• Partnership with oncology Nurse Practitioner

Regions

Advance Directives• Using the Honoring Choices and POLST forms• 56% of patients 65+ have Advance Directives

(1/11-2/12)• Lean project

– Design workflows to obtain Advance Directives and ensure copy is available in Epic

– Interdisciplinary effort (Palliative Care, Hospital Medicine, Nurse, Care Management, Chaplaincy, HIM)

– Comprehensive review of current process, identification of potential barriers, and ideas for new models

– Early fall 2012 goal for implementation

Health Plan

Disease & Case Management

• Staff training and awareness resulted in increased

referrals for Palliative Care, Advance Care Planning

and Hospice

• Advance Directive measure: 8543 patients screened,

3262 completed

• EBAN project successes spread to all patients/members

Hospice, Palliative Care & Adv Care Planning Referrals Disease & Case Management

EBAN Experience

• Eban is a letter from the Asanti people of Ghana. It

represents security, safety and trust. It was chosen

as the symbol of the EBAN Experience to represent

the coming together of cultures to improve the

health of all.

EBAN Experience

• Adopted by HealthPartners as an organizational

initiative for addressing health disparities and

equitable care in 2011.

• The EBAN Experience is a year-long collaborative of

teams created to address issues of health disparities

in the communities served by HealthPartners.

• Creative strategies that partner health care

professionals and community members.

EBAN Experience

• Areas of focus include:– Increased rates of advance directives– Increased pediatric immunization rates– Improve diabetes health outcomes through

education• Results

– Improved the rate of completed Advance Directives in the MSHO African-American population from 25% to 32% by year end.

– Narrowed the disparity gap between Whites and African Americans from 25% to 21%

Health Plan

• HealthPartners.com

• Current information in Health and Wellness tab in “Additional Resources”

Future Plans:• New “Care-giving Health Center” in Health &

Wellness tab will provide information on advance care planning, shared decision making, etc.

Primary Care

Advance Directives• Workflow is with care team, with Epic prompt and

notary• Pilots at Riverside, Brooklyn Center, Como, West for

patients 65+• Using short form with brochure and/or Honoring

Choices form• Expanding to all locations in 9/12 and then to

younger population, i.e, 50 and over• Staff Education

Specialty Care

Oncology• Sharing NP resource with Regions Palliative Care

• Population: new diagnosis, pancreatic and lung cancer, any stage 3 and 4

• Facilitated conversations with nurse practitioner or social worker

• Measure: since 1/11, 701 (23%) of all cancer patients have Advance Directives in EPIC

Specialty Care

Regions Heart Center

• Population: Heart Failure Class II, III, IV

• Providers initiate conversation then RN “facilitator”

meets with patient

• Measure: 83.5% of Class III and IV, 45% of Class II

have Advance Directives

Specialty Care

Nephrology• Population: Chronic Kidney Disease stage 4, 5• Provider initiates conversation then RN facilitation or

Advance Care Directives Class (group session), follow-up phone call

Beginning work: Pulmonary

Future work: Neurology

Geriatrics, Home Care, Hospice

Geriatrics/Home Care

• Standardized workflow, documents and where to

locate in EPIC.

• Measure: 75% with Advance Directives documented

• Increased long term care facility adoption of POLST

Geriatrics, Home Care, Hospice

Palliative Care/Hospice• Facilitated discussion with admission• Hospice measure: 960 of 1000 patients in 2011

completed POLST• Palliative Care measure: 273 admissions in 2011

with 227 completed Advance Directives using Honoring Choices Minnesota document

• Coordinating with inpatient Palliative Care consult team and weekly rounding

Community

• Alliance of Community Health Plans (ACHP) Palliative Care workgroup

• National Quality Forum (NQF) Hospice workgroup• Institute for Healthcare Improvement (IHI): The

Conversation Project by Ellen Goodman• EPIC and Health Information Exchange• End of Life training course with Jim Risser, MD and

Richard Heinrich, MD (2 days, twice a year)• St. Paul Area Council of Churches• EBAN project

Community

Honoring Choices Minnesota

• CEO and Senior Leadership support

• Member of Advisory Committee

• Ambassador Program participation (Kate Kellet with

primary)

REGIONS HEALTHPLAN PRIMARY CARE

SPECIALTY CARE

GERATRICS, HOME CARE & HOSPICE

COMMUNITY

• Inpatient and ED Palliative Care consult

• Outpatient resources for consultso Oncology clinic

partnership• Focus for FIT Quality

team• LEAN project:

Advance Directives• Measuring patient

anxiety and pain

• Palliative Care benefitoCommercialoMSHO

• Care and Disease ManagementoSpreading

learnings from EBAN projectoReferrals to

Palliative Care, Advance Care Planning, Hospice

• HealthPartners.com

• Advance Directive workflowoShort form,

brochure and/or Honoring Choices formoFacilitator

availableoPilots at

Riverside, Brooklyn Center, West, Como; to all sites 9/12

• Epic “prompt” on health maintenance screen

• Population Health workflow component

• Cardiology CHF patients class II, III and IVoHonoring choices

form and facilitator• Oncology

oNew cancer diagnosis patient identified in pre-visit planningoFocus on pancreatic,

lung and any Stage 3 and 4 cancers oHonoring choices

form and facilitator• Nephrology

oChronic Kidney Disease patients- stage 4 and 5 identified in pre-visit planningoHonoring Choices

form, facilitator or Advance Care Directives class

• Cardiology CHF All- Collaboration with hospice and palliative careoPulmonaryoNeurology

• Geriatrics/Home CareoHonoring choices

or POLST formoStandardized

workflow for EPIC or out of system providers and homecare EMRoNursing home

adoption of POLST form

• Palliative Care/HospiceoFacilitated

discussion on advance care planning at admissionoHonoring choices

or POLST formoCoordination

with inpatient palliative care consult team

• ICSI Workgroup• ACHP Palliative Care

workgroup• HIE/EPIC• Honoring Choices

MNoAmbassador

programoPublic television

• EBAN project• St Paul area Council

of Churches

Mary Lou Irvine, Tom von Sternberg MD, Donna Zimmerman, Beth Heinz

Mary Lou Irvine, Tom von Sternberg MD, Beth Werner

Terry Carter, Dave Slowinske, Tyler Schmidtz, Rachel Nygard

Kate KelletLora Hedin, Karen Kraemer

Jim Risser MD, Beth Heinz, Danielle TencateCole

HealthPartnersEnd of Life/Palliative Care Initiatives

Challenges/Opportunities

• Meeting cultural needs of patients

• EPIC modification that meets needs of community

• Limitation with Palliative Care benefit

• Improving website location and accessibility

(HealthPartners.com and My Partner)

• Building awareness

• Incorporating into Employee Wellness Program